Provider Demographics
NPI:1619915980
Name:WEST, CHARLES SHIRLEY JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:SHIRLEY
Last Name:WEST
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MEDICAL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4267
Mailing Address - Country:US
Mailing Address - Phone:864-271-7440
Mailing Address - Fax:864-271-6001
Practice Address - Street 1:28 MEDICAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4267
Practice Address - Country:US
Practice Address - Phone:864-271-7440
Practice Address - Fax:864-271-6001
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6683174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC068831Medicaid
SC068831Medicaid
SCC611886023Medicare ID - Type Unspecified
SCC611881372Medicare ID - Type Unspecified